THE ANTIBIOTIC BEAD POUCH TECHNIQUE - THE MANAGEMENT OF SEVERE COMPOUND FRACTURES

In a consecutive series of 704 compound fractures, 227 open fractures in 204 patients were managed with the antibiotic bead pouch technique. There were 16 Grade I compound fractures, 83 Grade II fractures, and 128 Grade III open fractures. The mean patient age was 35.25 years (ra nge, 14-87). The injury Severity Score (ISS) ranged from 9 to 57, with a mean of 15. Porous plastic film is placed over the soft-tissue defe ct to establish a ''closed'' bead-hematoma-fracture environment contai ning high local levels of antibiotic at the fracture site. All patient s had serial wound debridements and parenteral systemic antibiotics (c efazolin, tobramycin, penicillin). Bead pouch changes ranged from one to seven per patient (mean, two). During these changes, 1248 cultures were taken, 78 (6.25%) of which were positive in 34 patients. Seventee n patients developed clinical signs consistent with an infection. The wound infection rate was 0% in Grade I open fractures, 1.2% in Grade I I compound fractures, and 8.6% in Grade III open fractures. The osteom yelitis rate was 0% in Grade I compound fractures, 2.4% in Grade II op en fractures, and 5.5% in Grade III compound fractures. Wound closure was obtained in 134 fractures with delayed primary closure of the skin , in 53 fractures with flap coverage, and in 23 fractures with split-t hickness skin graft. Coverage was not completed in 17 wounds, at which time an amputation was performed or death occurred. Time of closure r anged from one to 32 days (mean, 7.1 days). The bead pouch technique d ecreases the incidence of infection and permits staged wound closure o f severe compound fractures.